Healthcare Provider Details

I. General information

NPI: 1992115588
Provider Name (Legal Business Name): AMBRISH PATEL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 THOMAS JOHNSON DR STE 3
FREDERICK MD
21702-4879
US

IV. Provider business mailing address

1205 E PINE ST KMART PHARNACY
DEMING NM
88030-7038
US

V. Phone/Fax

Practice location:
  • Phone: 240-422-8433
  • Fax: 301-662-0001
Mailing address:
  • Phone: 575-544-9008
  • Fax: 575-544-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007752
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number50775
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24518
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: